Image Sharing:The Cloud, the Roadmap, and the Business Models
Image sharing yields an impressive host of benefits. Patient care improves with timely physician access to images, and there are much-needed efficiency gains when examinations repeated due to the inability to access prior images are eliminated. While specifications for image exchange have surfaced in the past decade, few projects have advanced outside the walls of a single health-care entity. Proprietary solutions have proliferated, in the past year, in the form of software and technologies that leverage the Web (and cloud computing) to make image sharing possible among multiple hospitals, clinics, and imaging centers. Image-sharing projects, however, continue to be stymied by a raft of challenges on the business, legal, and clinical fronts; these include handling referrals, generating revenue, and grappling with patient-privacy issues.


Fox Chase Cancer Center One multifacility image-sharing project—undertaken by Fox Chase Cancer Center in Philadelphia, Pennsylvania—was born of an initiative to streamline the referral process and bolster referral rates. Fox Chase Cancer Center has a staff of 140 physicians, maintains a referral base of approximately 35,000 medical practitioners, and works with a network of about 26 partner health-care institutions in Pennsylvania’s Delaware Valley, as well as in New Jersey. Some 8,000 new cancer cases are added to its patient roster each year, with about 100,000 radiologic-oncology procedures performed annually. Not long ago, hospital decision makers concluded that a health information exchange (HIE) implementation was needed to address the volume of images and documents being generated in conjunction with such a heavy patient load. Asked what specific pain points the HIE should address, an overwhelming number of physicians (both on staff and from partner institutions) cited a lack of optimal access to images and laboratory results. Brian Vecchiarelli, clinical systems manager, says, “They wanted a full-bore, interfacility image-sharing system” that would transcend the problems inherent in the use of other image-transport vehicles, such as CDs. The Fox Chase HIE (FCHIE) allows the sharing of images among physicians at Fox Chase Cancer Center and its partner sites via password-protected Web portal and VPN. Rather than relying on remote, distributed image storage, as used in cloud-based configurations, FCHIE was designed so that images (and patient data) reside either in the hospital’s PACS or those of partner institutions. It is constructed on a proprietary HIE services platform that uses, as enabling tools, interoperability profiles published by Integrating the Health Enterprise (IHE). These include, on the image-sharing front, the Cross-enterprise Document Sharing for Imaging (XDS-I) integration profile. The DICOM standard constitutes another tool promoting image exchange employed by the hospital, in conjunction with the portal. Vecchiarelli says that the image-sharing portal addresses Fox Chase Cancer Center’s referral challenges, in large measure, by making it much easier for referring physicians to supply images and data to the hospital (and also to retrieve them). “A transport mechanism of this type is essential to our remaining a partner of choice for our own partners,” he says. Further leveraging the benefits of image exchange, the institution has constructed a clever business model for the HIE and, by extension, the portal. Under this aegis, partner institutions may—rather than merely using the portal to share images with Fox Chase Cancer Center—employ it to send images and associated data to the hospital for interpretation, on a fee-for-service basis. Two of the hospital’s partners have signed on for such services; marketing campaigns aimed at encouraging others partners to follow suit have been launched. “Early on in the process of building the HIE, it became clear to us that the grant monies we were allotted to fund it would probably be inadequate to sustain it on a long-term basis,” Vecchiarelli states. Going forward, the fee-for-interpretation piece will be a cornerstone of the financial framework for additional image sharing, beyond the hospital’s walls. Vecchiarelli adds that the solution’s key strength—“support for many, if not all, HIE standards”—will pave the way for one of Fox Chase Cancer Center’s next image- and information-sharing steps. He says, ”We want to make images and data available to patients through the portal.” Fox Chase Cancer Center sees that as a natural evolution in the continuum of care—and a move into the cloud is a strong possibility. The University of Wisconsin Hospital and Clinics Like Fox Chase Cancer Center, the University of Wisconsin Hospital and Clinics also has constructed a revenue-generating HIE platform with an image-sharing piece. Gary J. Wendt, MD, MBA, vice chair of informatics, professor of radiology, and enterprise director of medical imaging, describes this innovation as “an application service provider for PACS.” It is used by 14 client health-care organizations (hospitals and clinics of varying sizes) as a repository for (and link to) images and digital reports. “These sites themselves are separate entities; they have no common electronic medical record (EMR) and no physical equipment for image and data storage and exchange,” Wendt explains. “We maintain one PACS for all of them, and we maintain and manage the cloud,” which is built on a proprietary technology platform through which image (and data) sharing occur as a result of EMR integration. The PACS is linked to 60 different systems across the 14 client sites; images and data sent to the cloud come from nearly 1,100 DICOM devices. IHE integrated profile tools, notably XDS-I, are also part of the image-sharing tool kit. Wendt says that this mode of image exchange goes far toward helping the University of Wisconsin Hospital and Clinics and its client sites improve the caliber of patient care, as well as cutting down on the number of imaging procedures that payors might later deem excessive or inappropriate (and not reimbursable). As he elaborates, “Immediate access to images (in the cloud) is especially critical for us because we are a level I trauma center and a primary stroke center. The ability to view images before a patient arrives—or even before we accept a transfer—as well as the ability to avoid unnecessary transfers or decide on the necessary level (helicopter versus vehicle, for example) for an emergency transfer all have a positive impact on care.” At any site, he continues, additional positive effects come from “avoiding unnecessary travel time, planning resources before patients arrive, and having the opportunity to grab images captured at one facility quickly during follow-up care at another facility. The more imaging that can be put into one bucket, and the more consistent the images across sites—not in 3D at one site and another format in the next one—the better.” Leveraging the PHR Meanwhile, a move to place control of images and related examination data squarely in patients’ hands has given rise to RSNA’s Medical Image Sharing Project. Funded by the National Institutes of Health’s National Institute of Biomedical Imaging and Bioengineering to the tune of approximately $4.7 million, the two-year project centers on a standards-based workflow for populating personal health record (PHR) platforms with patients’ imaging data. David S. Mendelson, MD, FACR, is chief of clinical informatics and director of radiology information systems at the Mount Sinai Medical Center, New York, New York, as well as principal investigator for the Medical Image Sharing Project. When the proposal for the project came together in September 2009, he explains, “The prevailing thought was that giving patients control of their imaging histories (reports and images)—much in the same way they have a hand in other aspects of their lives, like online banking—would do away with a lot of the legal and privacy issues that come into play when institutions trade information and images, and these individuals are not directly involved.” He continues, “We were also aware of the disadvantages presented by existing image- and information-sharing solutions in that however elegant they are, they are also proprietary and, therefore, neither effective for exchange beyond the realm of local health-care entities nor particularly well priced.” In addition to the Mount Sinai Medical Center, project participants include the Mayo Clinic, Rochester, Minnesota, and the health-care systems of the University of Maryland, the University of California–San Francisco, and the University of Chicago. About 300,000 patients are expected to interact with the exchange over the course of the project’s two-year time window, Mendelson estimates. He explains that there are three components of the exchange: RSNA’s edge server, which acts as a conduit among the PACS/RIS of participating institutions and a vendor-neutral cloud archive or clearinghouse; the cloud technology platform itself, developed by a vendor; and individual, standards-compliant PHRs. All images and related report data from the five participating medical centers flow, via edge server, through the cloud to the participating PHR platforms. Whenever physicians or other providers need to review a report or images, patients can go online and sign on to the appropriate PHR, then view these items on the fly or initiate a full DICOM data transfer into a local archive or another PACS. Built on an IHE infrastructure, the cloud component includes an IHE registry, a repository, and IHE’s Patient Identifier Cross-reference Manager. The IHE XDS-I.b profile serves as the main transport mechanism between each imaging center and the edge server; the latter uses IHE XDS-I.b to access images from multiple PACS and reports from RIS, and it securely transports them to the clearinghouse. Patients employ one of three PHR mechanisms, Mendelson states. To address security concerns inherent in any online transfer of information, patients are assigned secure multidigit RSNA ID numbers and a PIN that is hidden from RSNA, much as a the PIN of a bank-card holder is not visible to the bank. When patients access their PHRs, they must re-enter the RSNA ID and the PIN to allow images to be accessed by the cloud. This is an adjunct to any security provided by individual PHRs. RSNA expects the first version of the project to go live in February 2011. Its funding extends through September 2011—two years after the wheels for the exchange were first set in motion—but Mendelson says that a long-term partnership with one of the vendors is likely. He notes that RSNA has no plans to own the image-sharing solution, citing a few different business models for operating it in the future. For example, while one prominent PHR vendor currently offers PHR access and accounts at no charge, patients could eventually be required to pay for these services. Alternatively, providers might opt to fund the solution themselves or to build the cost of image exchange into their own fees. Regardless of how the scenario unfolds, RSNA believes that the strength of the cloud-based solution lies in the fact that it was built on nonproprietary standards that should hasten adoption down the road. A weakness exists, too. Mendelson observes, “Clearly, image exchange in the cloud is tailored to individuals who are accustomed to using the Internet. Millions—or more likely, tens of millions of people—fall into this category. Some, however, will need additional hand holding.” The Canadian Effort In a related vein, all hospitals and clinics in Canada are engaging in image sharing as part of the implementation of a national EHR solution set to provide all Canadians with secure, interoperable lifetime records of their key health histories and care. Records will remain available electronically, anywhere and at any time, to authorized health-care providers and individuals, with the goal of facilitating the sharing of data across the continuum of care, health-care organizations, and geographic and other boundaries. Mark Nenadovic, MHSc, serves as Canada Health Infoway’s group director for its iEHR, laboratory information systems, diagnostic imaging, and patient access to quality care programs. He notes that while the EHR solution incorporates an image-sharing component, in part, because diagnostic imaging results, including images themselves, are considered a key component of patients’ health histories, it is also intended as a remedy for myriad other ills. Specifically, he says, 80% of Canadian health-care facilities are rural and have fewer than 250 beds. While such entities require PACS functionality in order to support the new solution, the bulk of PACS reside at large urban hospitals, and stand-alone PACS installation was not financially feasible for their smaller hospital and clinic counterparts. Moreover, while these smaller facilities offer diagnostic imaging services, many do not have on-site radiologists; rather, specialty services and associated physicians work primarily in a handful of regional and tertiary health-care facilities in Canada’s urban areas. Traditionally, this has impeded timely access to radiologist coverage and specialist consultation, bringing to bear quality-of-care issues—and often resulting in expensive (and frequently unnecessary) patient transfers. In addition, Nenadovic explains, the Canadian health-care system sees a considerable volume of interfacility patient referral and transfer, but without an image-sharing mechanism, physicians did not have ready access to diagnostic imaging records from other facilities, and an inordinate number of repeated diagnostic imaging procedures were being performed. Of the $2.1 billion (Canadian) in federal funds allocated to Infoway since its inception, $365 million has been earmarked for diagnostic imaging. Image sharing under Infoway occurs through a network of 19 vendor-neutral diagnostic imaging repositories that consolidate imaging results and, in hub-and-spoke fashion, provide a shared PACS application for those facilities that do not have PACS in place. “Essentially,” Nenadovic observes, “ours is a shared-utility model wherein small and rural hospitals can join larger, urban hospitals in the functionality that PACS provides, as well as the diagnostic imaging repositories’ archiving component. For example, 14 hospital sites in and around London, Ontario, are sharing one instance of a PACS solution maintained by the regional shared services group at the London Health Sciences Centre.” Nenadovic adds that Infoway’s standards collaborative has approved IHE’s XDS-I (and several related integration profiles) for use in allowing image sharing among the 19 image repositories. Several jurisdictions and their vendors are engaged in projects to comply with the integration standard. Almost all of Canada’s public hospitals are now filmless, Nenadovic says, with the exception of some smaller, remote locations in the Midwestern portion of the country. Provinces with private-sector imaging clinics are now working toward including their images in the archives. On the clinician side, Infoway’s image-sharing component is leading to timely consultations, improved workflow and efficiency, and optimal access to images and reports; on the patient side, it’s producing better care by reducing the waiting time for imaging procedures, by decreasing exposure to radiation from repeated examinations, and by improving remote access to specialists—with the ancillary benefit of lowering the number of transfers from referring hospitals to tertiary institutions. When the program is fully implemented, Nenadovic says, “The benefits have been estimated as being in the range of $850 million to $1 billion annually, across Canada.” Infoway’s project partners (Canada’s provinces and territories) have been co-investing in the project. Additional funding from the Canadian government is contingent on future health-care priorities. Julie Ritzer Ross is a contributing writer for Radiology Business Journal. Additional Reading — CDs: Migration Is Worth the Effort XDS-I: Blueprint for Image Exchange